Phacoemulsification without intraocular lens implantation in patients with high myopia: long-term results

PURPOSE

To estimate the cumulative incidence of postoperative retinal detachment (RD), rhegmatogenous retinal lesions requiring argon laser treatments, anterior (ACO) and posterior (PCO) capsule opacification, and neodymium:YAG (Nd:YAG) laser capsulotomy in patients with high myopia who had phacoemulsification without intraocular lens (IOL) implantation.

SETTING

Department of Ophthalmology and Neurosurgery, University of Siena, Siena, Italy.

METHODS

Seventy-three eyes of 57 patients with high myopia who had phacoemulsification without IOL implantation from 1993 to 1996 were retrospectively reviewed. The mean postoperative follow-up was 62.3 months and the mean axial length, 30.22 mm (range 29.10 to 33.70 mm). The incidence of RD and preoperative and postoperative prophylactic argon laser photocoagulation for rhegmatogenous retinal lesions were assessed. Between 1997 and 2000, ACO was evaluated subjectively and PCO was evaluated using the EPCO photographic image-analysis system. The incidence of Nd:YAG laser capsulotomy was noted.

RESULTS

Argon laser photocoagulation was performed in 8 eyes (10.9%) preoperatively and 3 eyes (4.1%) postoperatively. One RD (1.3%) was observed 26 months after surgery; no preoperative or postoperative prophylactic argon laser photocoagulation or Nd:YAG laser capsulotomy was performed in this eye. At 1 year, 49 eyes (67.1%) had mild ACO and 24 (32.8%) had anterior capsule fibrosis. The data did not change during subsequent follow-up visits. At 6 years, the mean PCO grade was 1.109 (range 0.972 to 2.931); an Nd:YAG laser capsulotomy was performed in 12 eyes (16.4%).

CONCLUSIONS

Compared with other studies that evaluated the outcomes of highly myopic patients who had cataract surgery with posterior chamber IOL implantation, our patients, who did not have IOL implantation, had a lower incidence of postoperative rhegmatogenous retinal lesions requiring argon laser treatments and a similar incidence of postoperative RD and visually significant PCO.

Thinning of the anterior capsule associated with congenital aniridia

PURPOSE

To report the unusual finding of intraoperative fragility of the anterior capsule in some patients with congenital aniridia and determine the histopathologic etiology of this finding.

SETTING

Cincinnati Eye Institute, Cincinnati, Ohio, USA.

METHODS

Anterior lens capsule specimens were obtained from aniridic and nonaniridic patients during cataract surgery. The intraoperative behavior of each capsule was noted, after which the specimens were submitted for histopathologic evaluation.

RESULTS

All anterior capsule specimens from the nonaniridic patients were of normal thickness. Some, but not all, anterior capsule specimens from the aniridic patients were remarkably thin. Thin capsules were associated with extreme intraoperative fragility.

CONCLUSIONS

Greater awareness of anterior capsule fragility in some aniridic patients may reduce the risk of capsule complications and lead to safer surgical outcomes.

Lens-induced astigmatism after perforating scleral injury

Within 6 weeks of a penetrating scleral injury that included vitreous prolapse, a 6-year-old boy developed lenticular astigmatism with a regular component of 5.5 diopters (D). Visible indentational folds in the posterior lens capsule, caused by anterior vitreous fibers and anterior hyaloid, were presumed to be the origin of the astigmatism. Because of decreased visual acuity and the suspicion of early amblyopia, a pars plana vitrectomy with removal of the anterior hyaloid and the critical anterior vitreous fibers was performed. Dense fibrotic tissue between the lens equator and the site of the original scleral perforation limited reduction of the preoperative astigmatism to 4.0 D. However, the striae-like lenticular deformation disappeared completely, and full visual acuity was restored. During the 12-month follow-up, the lens remained clear

Capsular block syndrome associated with horizontal jerk nystagmus

A 78-year-old cataract patient with horizontal jerk nystagmus had phacoemulsification and intraocular lens (IOL) implantation in the capsular bag with continuous curvilinear capsulorhexis. One week postoperatively, the posterior capsule ballooned posteriorly, the anterior capsule opening was sealed to the IOL optic, and a transparent liquefied substance accumulated between the lens optic and the posterior capsule. The best corrected visual acuity was 0.6 with a myopic shift compared with the refraction after the first day. A neodymium:YAG laser posterior capsulotomy was performed, and the capsular block syndrome (CBS) resolved. The results confirm the experimental model proposed by Zacharias suggesting that saccadic eye movements contribute to CBS under certain anatomic conditions.

[ND YAG laser impact for creating a pupil]

PURPOSE

Using the energy of Nd YAG laser for creating a pupil and achievement of best functional and esthetic effect.

MATERIAL AND METHODS

For creating a pupil in membranous cataract and pupillar membranes we used Nidek Nd YAG laser in 53 eyes with pseudophakia, senile and traumatic aphakia. We used individual method of approach in each eye. In some of the eyes a complex of laser treatment: membranectomy, iridectomy, anterior vitreolysis in several treatments. We defined the average power of the laser beam and the average number of applications for attaining best results.

RESULTS

The creation of pupil plan was connected with the immediate improvement of the visual acuity. In 41 of the eyes (77.35%) it reached value between 0.4 and 1.0. The IOP was compensated up to the 24th hour with local beta-block.

CONCLUSION

The use of the Nd YAG laser energy for creating a pupil is uninvasive, modern, spare microsurgical method. An excellent functional and esthetic effect was achieved and no adjacent tissue was damaged while using it in closed eye ball conditions.

Risk factors for secondary membrane formation after removal of pediatric cataract

PURPOSE

To evaluate the incidence of secondary membrane formation, factors that lead to its development, and the frequency of procedures to treat these membranes in children after cataract surgery.

SETTING

Department of Pediatric Ophthalmology, Children's Hospital of Pittsburgh, Pittsburgh, Pennsylvania, USA.

METHODS

Clinical records of 152 patients (190 eyes) who had cataract extraction between January 1986 and 1996 were reviewed retrospectively. The mean follow-up was 6 years (range 2 to 13 years). Cataract surgery was performed through a limbal incision in all cases. Twenty-eight eyes had a primary posterior capsulectomy, and 120 eyes had posterior capsulectomy combined with an anterior vitrectomy. In 42 eyes, the posterior capsule was left intact. Nineteen eyes received a primary intraocular lens (IOL), 15 eyes received a secondary IOL, and 156 eyes were rehabilitated with spectacles or contact lenses.

RESULTS

Seventy-two eyes (37.9%) developed secondary membrane a mean of 8.9 months postoperatively (range 3 weeks to 53 months). Membranes occurred in 78.6% of eyes with an intact posterior capsule, 42.9% with posterior capsulectomy, and 22.5% with combined posterior capsulectomy and anterior vitrectomy. Secondary membrane formation was associated with not performing a posterior capsulectomy with anterior vitrectomy (P < .001) and the presence of a primary IOL (P < .001). Younger age at surgery increased the chance of secondary membrane formation in patients who had posterior capsulectomy and anterior vitrectomy (P < .01).

CONCLUSIONS

The younger the child at cataract surgery, the greater the risk of secondary membrane. Primary posterior capsulectomy combined with an anterior vitrectomy decreased but did not eliminate the incidence of secondary membrane.

Capsular bag distention syndrome after combined cataract-lens implant surgery and Ahmed valve implantation

PURPOSE

To describe the capsular bag distention syndrome after combined cataract extraction with posterior lens implant and aqueous drainage device.

METHODS

Case report.

RESULTS

A persistently shallow anterior chamber and low intraocular pressure developed after combined cataract extraction with posterior chamber lens implant and Ahmed aqueous drainage device. An optically empty space between the lens implant and posterior capsule was detected 18 days after surgery. The anterior chamber deepened within minutes after Nd:YAG posterior capsulotomy.

CONCLUSION

The capsular bag distention syndrome needs to be included in the differential diagnosis of shallow anterior chamber with low intraocular pressure after combined cataract extraction and glaucoma valve implant surgery.

Management of posterior capsule rupture during phacoemulsification using the dry technique

To manage posterior capsule rupture during phacoemulsification, we use a dry technique in which all procedures are performed without an irrigation/aspiration system. The dry technique is characterized by (1) continuous viscoelastic injection instead of fluid irrigation to maintain anterior chamber depth with the posterior capsule and vitreous located posteriorly and (2) static removal of most residual lens material by viscoexpression and/or manual small incision extracapsular cataract extraction without aspiration and dynamic water flow. In 16 cases of posterior capsule rupture managed using the dry technique, the residual nucleus and cortex were readily removed with minimum extension of the ruptured area and new vitreous loss. Although large amounts of viscoelastic material (mean 5.8 mL) were required, rapid and stable visual recovery was comparable to that in patients having uneventful surgery. The dry system is a safe and reliable technique for managing posterior capsule rupture during phacoemulsification.

Traumatic lens abscess with chornic endophthalmitis successfully treated with pars plana lensectomy and vitrectomy

Intralenticular abscess is a rare entity and has been infrequently reported after surgery, metastatic infection, or trauma. We report a case of post traumatic lens abscess with low-grade endophthalmitis following a penetrating eye injury with a splinter of wood. The patient was successfully treated with a pars plana lensectomy and vitrectomy. Despite thorough microbiological investigations, no causative organism could be isolated.

Massive anterior capsule shrinkage after plate-haptic silicone lens implantation in uveitis

Two patients, both with bilateral uveitis, had synechiolysis, continuous curvilinear capsulorhexis (CCC), phacoemulsification, and in-the-bag implantation of a foldable single-piece plate-haptic silicone intraocular lens (IOL) in 1 eye. Several weeks postoperatively, massive anterior capsule shrinkage with obstruction of the visual axis occurred in both patients. Surgical revision was performed in both eyes. Both patients had CCC and phacoemulsification and confirmed in-the-bag acrylic IOL implantation in the second eye months after surgery in the first eye. Follow-up examinations showed no significant shrinkage of the anterior capsule opening in any eye. In patients with uveitis, intraoperative lens epithelial cell removal, creation of a large CCC, and careful selection of IOL style and material may prevent occlusion of the anterior capsule opening.

Fibrous congenital iris membranes with pupillary distortion

BACKGROUND

In 1986 Cibis and associates described 2 children with a new type of congenital pupillary-iris-lens membrane with goniodysgenesis that was unilateral, sporadic, and progressive. These membranes were different from the common congenital pupillary strands that extend from 1 portion of the iris collarette to another or from the iris collarette to a focal opacity on the anterior lens surface. They also differed from the stationary congenital hypertrophic pupillary membranes that partially occlude the pupil, originating from multiple sites on the iris collarette, but not attaching directly to the lens.

CASE MATERIAL

The present report is an account of 7 additional infants with congenital iris membranes, similar to those reported by Cibis and associates, which caused pupillary distortion and were variably associated with adhesions to the lens, goniodysgenesis, and progressive occlusion or seclusion of the pupil. Six of the 7 patients required surgery to open their pupils for visual purposes or to abort angle closure glaucoma. A remarkable finding was that the lenses in the area of the newly created pupils were clear, allowing an unobstructed view of normal fundi.

CONCLUSION

This type of fibrous congenital iris membrane is important to recognize because of its impact on vision and its tendency to progress toward pupillary occlusion. Timely surgical intervention can abort this progressive course and allow vision to be preserved.

True exfoliation of the lens capsule following uveitis

PURPOSE

To report a rare case of true exfoliation of the lens capsule following panuveitis, with slit-lamp photographs before and following the development of the true exfoliation.

METHODS

Case report. Review of the history and clinical features of a 70-year-old woman who developed true exfoliation during the treatment for panuveitis.

RESULTS

After 7 months of treatment for bilateral panuveitis with topical steroid and tropicamide, the patient developed a thin, transparent membrane arising on the lens surface in the right eye. A diagnosis of true exfoliation of the lens capsule was made.

CONCLUSIONS

True exfoliation of the lens capsule following uveitis may occur due to the weakening of the anterior capsule by metabolic disorder caused by uveitis and precipitated by repeated mydriasis.

Absence of ocular manifestations in autosomal dominant Alport syndrome associated with haematological abnormalties

Most patients with Alport syndrome have X-linked or autosomal recessive disease that is characterised by renal failure, hearing loss, and, in nearly 75% of the cases, a dot-and-fleck retinopathy and anterior lenticonus. There are only case reports of individuals with the rare autosomal dominant form, who can have haematuria or renal failure, deafness, and, in addition, low platelet counts and neutrophil inclusions. The ocular features of autosomal dominant inheritance have not been described. We have examined the eyes in the members of two families where Alport syndrome was diagnosed on the basis of the clinical features and family history, and where autosomal dominant inheritance was confirmed by father-to-son disease transmission, the associated haematological abnormalities, and haplotypes that segregated with the recently described locus at chromosome 22q. In Family A, the eyes of two individuals with haematuria, hearing loss, and haematological abnormalities and of nine unaffected family members were examined. In Family B, the eyes of two individuals with renal failure, normal hearing, and haematological abnormalities were examined. None of the affected or unaffected members in either family had a dot-and-fleck retinopathy, anterior lenticonus, a history suggesting recurrent corneal erosions, or corneal dystrophy. These results indicate that the protein abnormality in autosomal dominant Alport syndrome does not produce the retinopathy and lenticonus typical of X-linked and autosomal recessive disease. This may be because the abnormal protein is not present or is less important in the ocular basement membranes than elsewhere, or because the presence of a normal allele in autosomal dominant disease compensates for the defective allele.

Morphological study on rupture of posterior capsule in RLC mouse lens

PURPOSE

To clarify the causative factor underlying rupture of the posterior capsule of the RLC mouse lens as a recessive trait around the 50th postnatal day.

METHODS

The lenses of the RLC mouse were removed in the period from birth to 50th postnatal day. Some specimens were observed by light microscopy and transmission and scanning electron microscopy. Others were examined as flat preparations of the lens epithelium.

RESULTS

There was an abnormal arrangement of lens fibers at the newborn stage, and lens fibers of the perinuclear zone ended almost vertical in relation to the posterior capsule. Consequently, the posterior suture was not formed in this mouse lens. On the 10th postnatal day, the ends of the lens fibers that terminated in the posterior capsule became swollen, and the posterior capsule at the posterior polar region became thin. On the 20th day, the area of swollen fibers was so large at the center of the posterior capsule that a vacuolated area was observed under the dissecting microscope. On the 30th day, the posterior cortical fibers in this area showed marked swelling, and the posterior capsule became extremely thin. On the 40th day, the anterior cortex became unusually thick, and the lens nucleus was dislocated towards the posterior capsule. On the 50th day, the posterior capsule ruptured. At this time the lens fibers from the perinuclear zone constituted the central area of rupture, and the cortical fibers from the equator formed the protruded area outside the lens.

CONCLUSION

The findings revealed that the RLC mouse lens has an abnormal lens fiber arrangement from the early period of lens development, that the lens fibers from the perinuclear zone cause swelling without forming the posterior suture, and that the thin capsule is ruptured by pushing out of the nucleus by thickening of the anterior cortex.

Silicone intraocular lens compression and double lens implants in diseased eyes

PURPOSE

To assess the outcomes of double lens implants in hyperoptic eyes with associated pathology.

METHOD

Double lens implants were used in 4 eyes of 4 patients each with a different ophthalmic or neuro-ophthalmic disease. Biometry was performed in the standard contact fashion and lens power formulae used included SRK/T, Holladay and Hoffer Q.

RESULTS

Average spherical equivalent refraction improved from +6.875 D to +0.38 D. Absolute average prediction error was greatest for SRK/T (2.65 D) and least for Holladay (1.73 D). Refractive suprises were influenced by the underlying disease process. One patient showed central lens compression.

CONCLUSION

Underlying disease can produce biometry errors. Structural ophthalmic or neurological disease is not a contraindication to the use of double lens implants. Double lens implants are useful to correct refractive error in the presence of underlying disease.

Complete capsular bag distension syndrome

After conventional extracapsular cataract extraction and in-the-bag intr aocular lens (IOL) implantation 3 years previously, the partially cut su perior one-third of the anterior capsulotomy flap resealed in the eye of a 55-year-old woman. With the integrity of the capsular bag restored, it distended fully; the IOL was in the center and milky fluid accumulated inside. A neodymium:YAG laser was used to drain the milky fluid and di srupt the opacified anterior and posterior capsules, restoring vision.

Capsular block syndrome and pseudoexpulsive hemorrhage

Capsular block syndrome (CBS) has been recognized as a cause of immediate or delayed postoperative accumulation of fluid behind an intraocular lens/capsulorhexis complex. Hydrodissection-related rupture of the posterior capsule may be considered a variant of CBS that can manifest intraoperatively. We describe another intraoperative situation related to CBS in which fluid loculation during hydrodissection mimics a threatened expulsive hemorrhage.

Ultrasonographic measurement of induced myopia associated with capsular bag distention syndrome

OBJECTIVE

To determine the causes of postoperative myopia associated with capsular bag distention syndrome (CBDS) and characterize the associated findings.

DESIGN

Prospective, multicenter, nonrandomized, comparative (self-controlled) trial.

PARTICIPANTS

Six eyes from six patients had CBDS develop after phacoemulsification and posterior chamber intraocular lens implantation.

METHODS

Keratometric values, axial length, visual acuity, and manifest refraction were assessed in each eye. Using 20-MHz (I3SYSTEM-ABD, Innovative Imaging Inc, Sacramento, CA) and 50-MHz (Ultrasound Biomicroscope, Zeiss Humphrey Systems, Dublin, CA) ultrasonographic probes, images and measurements of the anterior segment were obtained. After neodymium:yttrium-aluminum-garnet (Nd:YAG) capsulotomy, these measures were repeated and correlated with predicted and actual refractive changes.

MAIN OUTCOME MEASURES

Uncorrected visual acuity (UCVA), best-corrected visual acuity (BCVA), manifest refraction, and anterior chamber depth before and after treatment of CBDS.

RESULTS

Although intended postoperative refraction averaged -0.58 diopters (D) (range, -0.12 to -1.63 D), eyes with CBDS had an average spherical equivalent refraction of -2.35 D (range, +0.13 to -4.50 D), P < 0.05 (one-tailed, paired t test). BCVA averaged 20/24 (range, 20/15-20/40-1), but UCVA averaged 20/133 (range, 20/60 to 20/400). Average distance from the corneal surface to the anterior intraocular lens (IOL) optic surface was 3.55 mm in eyes with CBDS, and 4.30 mm after Nd:YAG capsulotomy. Posterior movement of the IOL optic after capsulotomy accounted for 1.23 D of hyperopic shift or 82% of the CBDS-induced myopia. Treatment of CBDS resulted in both improved UCVA and BCVA. Nd:YAG capsulotomy also released the colloidal suspension within the capsular bag posterior to the IOL optic. The incidence of CBDS was 0.3% in one of the practices reviewed.

CONCLUSIONS

Capsular bag distention syndrome includes unexpected myopia and poor UCVA after cataract surgery with lens implantation in cases involving a continuous capsulorhexis. A dramatic posterior distention of the posterior capsule is observed, as well as anterior chamber shallowing, tight apposition of the iris to the IOL, and anterior bowing of the iris. A slightly turbid colloidal suspension behind the IOL implant and late posterior capsular fibrosis are also observed. Timely treatment of CBDS can correct unwanted myopia, improve UCVA and BCVA, and restore normal anatomic relationships in the eye.

Early postoperative capsular block syndrome related to saccadic-eye-movement-induced fluid flow into the capsular bag

PURPOSE

To determine the relationship between saccadic eye movements and the development of early postoperative capsular block syndrome.

SETTING

Fundacion Oftalmologica, Los Andes, Santiago, Chile.

METHODS

An artificial experimental setup was designed to reproduce the anatomical, hydrodynamic, and kinetic conditions of an early postoperative pseudophakic eye with a capsulorhexis and intracapsular intraocular lens (IOL) implantation. An electromechanical transducer driven by a digital-to-analog converter was used to mimic saccadic eye movements at physiological speeds and accelerations. Position information and differential pressure measurements between the intracapsular space and the extracapsular space were digitized. Various anterior capsule-IOL configurations were tested including partial adhesion of the anterior capsule to the lens.

RESULTS

Saccadic movements increased intracapsular pressure by displacing fluid into the capsular bag. This finding was inconstant and only observed when the capsular rim adhered to the IOL optic by more than 70%. Development of positive intracapsular pressure was noted above 4 mm Hg.

CONCLUSION

A valve-like mechanism formed by the capsulorhexis rim partially adhered to the IOL optic can occur postoperatively. Under these conditions, saccadic eye movements can increase intracapsular pressure by a unidirectional inertial displacement of fluid into the capsular bag.